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We evaluate the impact of oral polio vaccines on the incidence of all disabilities (locomotor, hearing, visual, speech, and mental) in India, focusing on polio-related disability, which constitutes the largest fraction of locomotor disabilities. Polio was hyperendemic in India even as recently as the early 1990s, but the country was declared wild polio virus-free in 2014. Intent-to-treat effects from difference-in-differences with multiple time period models that condition on demographic and socio-economic characteristics reveal that access to oral polio vaccines in the year of birth reduced the incidence of any disability, locomotor disability, and polio-related disability by 20.5%, 11.6%, and 7.2%, respectively, signaling substantial gains. Impacts on any disability underline that polio vaccines had positive spillover effects on other disability categories as well. The eradication of polio in India, while relatively late, brought significant health benefits and is a notable health economics success story in a developing context. [ABSTRACT FROM AUTHOR]

Policy Points: Significant advances in clinical medicine that have broader societal relevance may be less accessible to population health researchers and policymakers because of increased specialization within fields. We describe important recent clinical advances and discuss their broader societal impact. These advances include more expansive strategies for disease prevention, the rise of precision medicine, applications of human microbiome research, and new and highly successful treatments for hepatitis C infection. These recent developments in clinical research raise important issues surrounding health care costs and equitable resource allocation that necessitate an ongoing dialogue among the fields of clinical medicine, population health, and health policy. Context: Developments in clinical medicine have important implications for population health, and there is a need for interdisciplinary engagement among clinical medicine, the social sciences, and public health research. The aim of this article is to help bridge the divide between these fields by exploring major recent advances in clinical medicine that have important implications for population health. Methods: We reviewed the most cited articles published from 2010 to 2015 in 5 high‐impact clinical journals and selected 5 randomized controlled trials and 2 related clinical practice guidelines that are broadly relevant to population health and policy. Findings: We discuss the following themes: (1) expanding indications for drug therapy and the inherent medicalization of the population as highlighted by studies and clinical guidelines supporting lower blood pressure targets or widespread statin use; (2) the tension in nutritional research between quantifying the impact of isolated nutrients and studying specific foods and dietary patterns, for example, the role of the Mediterranean diet in the primary prevention of cardiovascular disease; (3) the issue of high medication costs and the challenge of providing equitable access raised by the development of new and effective treatments for hepatitis C infection; (4) emerging clinical applications of research on the human microbiome as illustrated by fecal transplant to treat Clostridium difficile infections; and (5) the promise and limitations of precision medicine as demonstrated by the rise of novel targeted therapies in oncology. Conclusions: These developments in clinical science hold promise for improving individual and population health and raise important questions about resource allocation, the role of prevention, and health disparities. [ABSTRACT FROM AUTHOR]

An estimated 3.1 million children die each year because of undernutrition. Although cross-sectional and longitudinal studies have found a protective association between greater parental education and undernutrition in their children, no randomized trial has identified a causal effect, to our knowledge. Using the 1980 education reform in Zimbabwe as a natural experiment, we estimated the causal effect of additional parental schooling on the probability of anthropometric failure in their children under 5 years of age (ages 3 through 59 months). Analyzing data on 8,243 children from the 1988, 1999, 2005-2006, and 2010-2011 Demographic and Health Surveys, we found no effect of parental schooling on early childhood undernutrition at the national level in Zimbabwe. Among households in the urban and high-wealth-index subsamples, each additional year of maternal schooling led to absolute reductions in the probability of a child's being wasted of 5.2 percentage points (95% confidence interval (CI): -9.3, -1.2) and 3.6 percentage points (95% CI: -6.9, -0.4), respectively. In the subsample of children between the ages of 3 and 23 months, each additional year of paternal schooling increased the probability of a child's being stunted by 9.6 percentage points (95% CI: 1.4, 17.9). Secondary schooling alone may not be enough to improve early childhood nutrition in low-resource settings. [ABSTRACT FROM AUTHOR]

Objective: Racial/ethnic minorities in the U.S. have a higher prevalence of type 2 diabetes mellitus (T2DM) than white adults. While many independent risk factors for T2DM have been identified, these determinants are often viewed in isolation without considering the joint contributions of competing risk factors. The objective of this study was to assess the relative contributions of six domains of influence to racial/ethnic disparities in T2DM.Research Design and Methods: Cross-sectional analyses were conducted using the Boston Area Community Health III Survey (2010-2012), the third wave of a population-based sample of men and women from three racial/ethnic groups (black, Hispanic, white) living in Boston, Massachusetts (N = 2,764). Prevalent diabetes was defined by self-report of T2DM, fasting glucose >125 mg/dL, or HbA1c ≥6.5%. Structural equation models were constructed to evaluate the direct effects of each conceptual domain of influence on T2DM prevalence, as well as their indirect effects on the race/ethnicity-T2DM relationship. All direct and indirect pathways were included.Results: The final model indicated that 38.9% and 21.8% of the total effect of black race and Hispanic ethnicity, respectively, on T2DM prevalence was mediated by the socioeconomic, environmental, psychosocial, and lifestyle/behavioral risk scores. The largest mediating influence was the socioeconomic risk score, which explained 21.8% and 26.2% of the total effect of black race and Hispanic ethnicity, respectively.Conclusions: Our study found that socioeconomic factors had the greatest impact on explaining the excess prevalence of T2DM among racial/ethnic minorities. [ABSTRACT FROM AUTHOR]

Background: The global burden of child undernutrition is concentrated in South Asia, where gender inequality and female educational disadvantage are important factors. Maternal health literacy is linked to women's education and empowerment, can influence multiple malnutrition determinants, and is rapidly modifiable.Objective: This study investigated whether maternal health literacy is associated with child undernutrition in 2 resource-poor Indian populations.Methods: We conducted cross-sectional surveys in an urban and a rural site, interviewing 1 woman with a child aged 12-23 mo/household. Multivariate logistic regression analyses were conducted independently for each site. The main exposure was maternal health literacy. We assessed respondents' ability to understand, appraise, and apply health-related information with the use of Indian health promotion materials. The main outcomes were severe stunting, severe underweight, and severe wasting. We classified children as having a severe nutritional deficiency if their z score was <-3 SDs from the WHO reference population for children of the same age and sex. Analyses controlled for potential confounding factors including parental education and household wealth.Results: Rural and urban analyses included 1116 and 657 mother-child pairs, respectively. In each site, fully adjusted models showed that children of mothers with high health literacy had approximately half the likelihood of being severely stunted (rural adjusted OR: 0.50; 95% CI: 0.33, 0.74; P = 0.001; urban adjusted OR: 0.58; 95% CI: 0.35, 0.94; P = 0.028) or severely underweight (rural adjusted OR: 0.57; 95% CI: 0.38, 0.87; P = 0.009; urban adjusted OR: 0.48; 95% CI: 0.25, 0.91; P = 0.025) than children of mothers with low health literacy. Health literacy was not associated with severe wasting.Conclusions: In resource-poor rural and urban settings in India, maternal health literacy is associated with child nutritional status. Programs targeting health literacy may offer effective entry points for intervention. [ABSTRACT FROM AUTHOR]

Unintentional injury is the fourth leading cause of death in the United States, and mortality due to injury has risen over the past decade. The social determinants behind these rising trends have not been well documented. This study examines the relationship between county-level poverty and unintentional injury mortality in the United States from 1999–2012. Complete annual compressed mortality and population data for 1999–2012 were obtained from the National Center for Health Statistics and linked with census yearly county poverty measures. The outcomes examined were unintentional injury fatalities, overall and by six specific mechanisms: motor vehicle collisions, falls, accidental discharge of firearms, drowning, exposure to smoke or fire, and unintentional poisoning. Age-adjusted mortality rates and time trends for county poverty categories were calculated, and multivariate negative binomial regression was used to determine changes over time in both the relative risk of living in high poverty concentration areas and the population attributable fraction. Age-adjusted mortality rates for counties with > 20% poverty were 66% higher mortality in 1999 compared with counties with < 5% poverty (45.25 vs. 27.24 per 100,000; 95% CI for rate difference 15.57,20.46), and that gap widened in 2012 to 79% (44.54 vs. 24.93; 95% CI for rate difference 17.13,22.09). The relative risk of living in the highest poverty counties has increased for all injury mechanisms with the exception of accidental discharge of firearms. The population attributable fraction for all unintentional injuries rose from 0.22 (95% CI 0.13,0.30) in 1999 to 0.35 (95% CI 0.22,0.45) in 2012. This is the first study that uses comprehensive mortality data to document the associations between county poverty and injury mortality rates for the entire US population over a 14 year period. This study suggests that injury reduction interventions should focus on areas of high or increasing poverty. [ABSTRACT FROM AUTHOR]

Stunting and chronic undernutrition among children in South Asia remain a major unresolved global health issue. There are compelling intrinsic and moral reasons to ensure that children attain their optimal growth potential facilitated via promotion of healthy living conditions. Investments in efforts to ensure that children's growth is not faltered also have substantial instrumental benefits in terms of cognitive and economic development. Using the case of India, we critique three prevailing approaches to reducing undernutrition among children: an over ‐ reliance on macroeconomic growth as a potent policy instrument, a disproportionate focus on interpreting undernutrition as a demand ‐ side problem and an over ‐ reliance on unintegrated single ‐ factorial (one at a time) approaches to policy and research. Using existing evidence, we develop a case for support ‐ led policy approach with a focus on integrated and structural factors to addressing the problem of undernutrition among children in India. Key messagesEliminating child undernutrition is important from an intrinsic perspective and offers considerable instrumental benefits to individual and society.Evidence suggests that an exclusive reliance on a growth ‐ mediated strategy to eliminate stunting needs to be reconsidered, suggesting the need for a substantial support ‐ led strategy.Interpreting and addressing undernutrition as a demand ‐ side problem with proximal single ‐ factorial interventions is futile.There is an urgent need to develop interventions that address the broader structural and upstream causes of child undernutrition. [ABSTRACT FROM AUTHOR]

In this review, the potential causes and consequences of adult height, a measure of cumulative net nutrition, in modern populations are summarized. The mechanisms linking adult height and health are examined, with a focus on the role of potential confounders. Evidence across studies indicates that short adult height (reflecting growth retardation) in low- and middle-income countries is driven by environmental conditions, especially net nutrition during early years. Some of the associations of height with health and social outcomes potentially reflect the association between these environmental factors and such outcomes. These conditions are manifested in the substantial differences in adult height that exist between and within countries and over time. This review suggests that adult height is a useful marker of variation in cumulative net nutrition, biological deprivation, and standard of living between and within populations and should be routinely measured. Linkages between adult height and health, within and across generations, suggest that adult height may be a potential tool for monitoring health conditions and that programs focused on offspring outcomes may consider maternal height as a potentially important influence. [ABSTRACT FROM AUTHOR]

Background: Generalized interpersonal trust (as an indicator of social capital) has been linked to health status at both the individual and ecological level. We sought to examine how changes in contextual and individual trust are associated with changes in self-rated health in the European Social Surveys 2002-12. Methods: A multilevel analysis using a variance components model was performed on 203 452 individuals nested within 145 country cohorts covering 35 countries. Conditional on sociodemographic covariates, we sought to examine the association between self-rated health and individual trust, country average trust and a cross-level interaction between the two. Results: Although individual trust perceptions were significantly correlated with self-rated health [OR = 0.95, 95% confidence interval (0.94-0.96)], country-level trust was not associated [OR = 1.12, 95% confidence interval (0.95-1.32)]. There was, however, a strong crosslevel interaction between contextual and individual trust (P< 0.001), such that individuals with high interpersonal trust reported better health in contexts in which other individuals expressed high average interpersonal trust. Conversely, low trust individuals reported worse health in high trust contexts. Conclusion: Our findings suggest that contexts with increasing average trust can be harmful for low trust individuals, which might reflect the negative impact that social capital can have in certain groups. These findings suggest that contextual trust has a complex role in explaining health inequalities and individual self-rated health. [ABSTRACT FROM AUTHOR]

Jason Block and S. V. Subramanian explore avenues for improving the health of Americans through reducing dietary inequalities and look at whether concern over "food deserts" has been taken too far. [ABSTRACT FROM AUTHOR]

Previous research has provided conflicting evidence regarding fetal roots of adiposity in India. To compare the strength of association between maternal and paternal body mass indexes (BMIs) corrected for height with offspring BMI in India to examine the potential for intrauterine mechanisms to influence offspring adiposity in India, we analysed a sample of 16,528 mother-father-offspring trios from the 2005 to 2006 Indian National Family Health Survey. Children were aged 0-59 months with parents aged 15-49 years (mothers) and 15-54 years (fathers). Linear and logistic regression models, specified in multiple ways, were used to estimate associations between parental BMI* (BMI redefined by power term x (kg/m(x)) to be independent from height), and child BMI/top decile of child BMI. Higher values of maternal BMI and paternal BMI were associated with higher values of offspring BMI. In comparing the effects of maternal BMI and paternal BMI, however, no consistent differences were found in the strength of these parental influences on offspring BMI. In the fully adjusted linear model, the standardised coefficient was 0.131 (95% CI 0.110 to 0.154) for maternal BMI* and 0.079 (95% CI 0.056 to 0.103) for paternal BMI*; with evidence of heterogeneity between maternal-offspring and paternal-offspring associations (p=0.005). This was not robust in the unstandardised regression (β=0.056, 95% CI 0.044 to 0.067 for maternal BMI and β=0.039, 95% CI 0.025 to 0.053 for paternal BMI, p=0.093). Mixed results indicate that compared with paternal BMI, maternal BMI did not have a consistently stronger influence on offspring BMI in India. [ABSTRACT FROM AUTHOR]

Background Education of mothers may improve child health. We investigated whether maternal health literacy, a rapidly modifiable factor related to mother's education, was associated with children's receipt of vaccines in two underserved Indian communities. Methods Cross-sectional surveys in an urban and a rural site. We assessed health literacy using Indian child health promotion materials. The outcome was receipt of three doses of diphtheria-tetanus-pertussis (DTP3) vaccine. We used multivariate logistic regression to investigate the relationship between maternal health literacy and vaccination status independently in each site. For both sites, adjusted models considered maternal age, maternal and paternal education, child sex, birth order, household religion and wealth quintile. Rural analyses used multilevel models adjusted for service delivery characteristics. Urban analyses represented cluster characteristics through fixed effects. Results The rural analysis included 1170 women from 60 villages. The urban analysis included 670 women from nine slum clusters. In each site, crude and adjusted models revealed a positive association between maternal health literacy and DTP3. In the rural site, the adjusted OR was 1.57 (95% CI 1.11 to 2.21, p=0.010) for those with medium health literacy, and OR=1.30 (95% CI 0.89 to 1.91, p=0.172) for those with high health literacy. In the urban site, the adjusted OR was 1.10 (95% CI 0.65 to 1.88, p=0.705) for those with medium health literacy, and OR=2.06 (95% CI 1.06 to 3.99, p=0.032) for those with high health literacy. Conclusions In these study settings, maternal health literacy is independently associated with child vaccination. Initiatives targeting health literacy could improve vaccination coverage. [ABSTRACT FROM AUTHOR]

Objective:To analyse whether an individual's neighbourhood influences the uptake of weight management strategies and whether there is an interaction between individual socio-economic status and neighbourhood deprivation.Methodology:Data were collected from the Yorkshire Health Study (2010-2012) for 27 806 individuals on the use of the following weight management strategies: 'slimming clubs', 'healthy eating', 'increasing exercise' and 'controlling portion size'. A multi-level logistic regression was fit to analyse the use of these strategies, controlling for age, sex, body mass index, education, neighbourhood deprivation and neighbourhood population turnover (a proxy for neighbourhood social capital). A cross-level interaction term was included for education and neighbourhood deprivation. Lower Super Output Area was used as the geographical scale for the areal unit of analysis.Results:Significant neighbourhood effects were observed for use of 'slimming clubs', 'healthy eating' and 'increasing exercise' as weight management strategies, independent of individual- and area-level covariates. A significant interaction between education and neighbourhood deprivation was observed across all strategies, suggesting that as an area becomes more deprived, individuals of the lowest education are more likely not to use any strategy compared with those of the highest education.Conclusions:Neighbourhoods modify/amplify individual disadvantage and social inequalities, with individuals of low education disproportionally affected by deprivation. It is important to include neighbourhood-based explanations in the development of community-based policy interventions to help tackle obesity. [ABSTRACT FROM AUTHOR]

Background: Sleep plays an important role in health and varies by social determinants. Little is known, however, about geographic variations in sleep and the role of individual-level and neighbourhood-level factors. Methods: We used a multilevel modelling approach to quantify neighbourhood variation in self-reported sleep duration (very short <5 h; short 5–6.9 h; normative 7–8.9 h; long ≥9 h) among 3591 participants of the Boston Area Community Health Survey. We determined whether geographic variations persisted with control for individual-level demographic, socioeconomic status (SES) and lifestyle factors. We then determined the role of neighbourhood SES (nSES) in geographic variations. Additional models considered individual health factors. Results: Between neighbourhood differences accounted for a substantial portion of total variability in sleep duration. Neighbourhood variation persisted with control for demographics, SES and lifestyle factors. These characteristics accounted for a portion (6–20%) of between-neighbourhood variance in very short, short and long sleep, while nSES accounted for the majority of the remaining between-neighbourhood variances. Low and medium nSES were associated with very short and short sleep (eg, very short sleep OR=2.08; 95% CI 1.38 to 3.14 for low vs high nSES), but not long sleep. Further inclusion of health factors did not appreciably increase the amount of between-neighbourhood variance explained nor did it alter associations. Conclusions: Sleep duration varied by neighbourhood in a diverse urban setting in the northeastern USA. Individual-level demographics, SES and lifestyle factors explained some geographic variability, while nSES explained a substantial amount. Mechanisms associated with nSES should be examined in future studies to help understand and reduce geographic variations in sleep. [ABSTRACT FROM AUTHOR]

In contrast to a large literature investigating neighborhood effects on health, few studies have examined health as a determinant of neighborhood attainment. However, the sorting of individuals into neighborhoods by health status is a substantively important process for multiple policy sectors. We use prospectively collected data on 569 poor, predominantly African American Hurricane Katrina survivors to examine the extent to which health problems predicted subsequent neighborhood poverty. Our outcome of interest was participants' 2009-2010 census tract poverty rate. Participants were coded as having a health problem at baseline (2003-2004) if they self-reported a diagnosis of asthma, high blood pressure, diabetes, high cholesterol, heart problems, or any other physical health problems not listed, or complained of back pain, migraines, or digestive problems at baseline. Although health problems were not associated with neighborhood poverty at baseline, those with baseline health problems ended up living in higher poverty areas by 2009-2010. Differences persisted after adjustment for personal characteristics, baseline neighborhood poverty, hurricane exposure, and residence in the New Orleans metropolitan area, with baseline health problems predicting a 3.4 percentage point higher neighborhood poverty rate (95% confidence interval: 1.41, 5.47). Results suggest that better health was protective against later neighborhood deprivation in a highly mobile, socially vulnerable population. Researchers should consider reciprocal associations between health and neighborhoods when estimating and interpreting neighborhood effects on health. Understanding whether and how poor health impedes poverty deconcentration efforts may help inform programs and policies designed to help low-income families move to--and stay in--higher opportunity neighborhoods. [ABSTRACT FROM AUTHOR]

This study estimates the effects of the COVID-19 pandemic on life satisfaction and stress and examines whether these effects vary across different sociodemographic groups using a nationally representative sample in South Korea. We estimate the causal effects of COVID-19 on psychological well-being by exploiting regional variation in the spread of the pandemic in South Korea. While the number of confirmed cases was very small in other provinces in the first half of 2020, the coronavirus spread rapidly in Daegu after an outbreak in one church. We employ a difference-in-differences approach that compares changes in people's life satisfaction and stress before-and-after the initial surge of COVID-19 cases in Daegu and other provinces. Our results show that the proportion of people who are dissatisfied with life increased by 2.8–6.5 percentage points more in Daegu than in other provinces after the COVID-19 outbreak. During the same period, the proportion of people who reported feeling stressed increased more in Daegu than in other provinces by 5.8–8.9 percentage points. Our results also suggest that the negative impact of the COVID-19 outbreak on psychological well-being is significantly greater for men, young adults, middle-aged adults, self-employed workers, and middle-income individuals. On the other hand, the proportion of people who report feeling stressed among the highest-educated (a master's degree or higher) and high-income individuals decreased after the onset of the COVID-19 outbreak. [ABSTRACT FROM AUTHOR]

The article focuses on need for policy deliberations on improving health in low- and middle-income countries (LMICs). It discusses how education influences health and importance of International Monetary Fund for attainment of education in LMICs. It provides analysis of country-specific heterogeneity in the relationship between education and health.

Objective To provide new evidence on whether and how patterns of health care utilization deviate from horizontal equity in a country with a universal and egalitarian public health care system: Italy. Data Sources Secondary analysis of data from the Health Conditions and Health Care Utilization Survey 2005, conducted by the Italian National Institute of Statistics on a probability sample of the noninstitutionalized Italian population. Study Design Using multilevel logistic regression, we investigated how the probability of utilizing five health care services varies among individuals with equal health status but different SES. Data Collection/Extraction Respondents aged 18 or older at the interview time ( n = 103,651). Principal Findings Overall, we found that use of primary care is inequitable in favor of the less well-off, hospitalization is equitable, and use of outpatient specialist care, basic medical tests, and diagnostic services is inequitable in favor of the well-off. Stratifying the analysis by health status, however, we found that the degree of inequity varies according to health status. Conclusions Despite its universal and egalitarian public health care system, Italy exhibits a significant degree of SES-related horizontal inequity in health services utilization. [ABSTRACT FROM AUTHOR]

Background: Infant and child mortality rates are among the most important indicators of child health, nutrition, implementation of key survival interventions, and the overall social and economic development of a population. In this paper, we investigate the role of coverage of maternal and child health (MNCH) interventions in contributing to declines in child mortality in sub-Saharan Africa. Design: Data are from 81 Demographic and Health Surveys from 35 sub-Saharan African countries. Using ecological time-series and child-level regression models, we estimated the effect of MNCH interventions (summarized by the percent composite coverage index, or CCI) on child mortality with in the first 5 years of life net of temporal trends and covariates at the household, maternal, and child levels. Results: At the ecologic level, a unit increase in standardized CCI was associatedwith a reduction in under-5 child mortality rate (U5MR) of 29.0 per 1,000 (95% CI: 43.2, 14.7) after adjustment for survey period effects and country-level per capita gross domestic product (pcGDP). At the child level, a unit increase in standardized CCI was associated with an odds ratio of 0.86 for child mortality (95% CI: 0.820.90) after adjustment for survey period effect, country-level pcGDP, and a set of household-, maternal-, and child-level covariates. Conclusions: MNCH interventions are important in reducing U5MR, while the effects of economic growth in sub-Saharan Africa remain weak and inconsistent. Improved coverage of proven life-saving interventions will likely contribute to further reductions in U5MR in sub-Saharan Africa. [ABSTRACT FROM AUTHOR]

Improving maternal nutrition is an important step toward reducing low birth weight (LBW) and its sequelae. In India, an estimated 7.5 million babies are born each year with LBW, which accounts for more than one-third of the global burden. In this context, little is known about the population-level association of iron and folic acid supplementation (IFA) during pregnancy and reducing the outcome of LBW. Using pooled data from the nationally representative 1998/1999 and 2005/2006 National Family Health Surveys of India, we examined the association of IFA with LBW and birth weight using multivariable logistic and linear regression models, respectively (n = 22,648). We found that IFA during pregnancy was negatively associated with LBW after adjustment for socioeconomic status [OR = 0.77 (95% CI: 0.68, 0.87); P < 0.001] and further adjustment for antenatal care (ANC) utilization [OR = 0.82 (95% CI: 0.72, 0.94); P < 0.001]. This corresponded to a 41-g [(95% CI: 2 g, 80 g); P < 0.05] increase in birth weight, which attenuated to 28 g [(95% CI: -12 g, 68 g); P = 0.71] after additional adjustment for ANC. At the population level in a context where the burden of anemia is severe (prevalence ≥40%), IFA during pregnancy was significantly associated with decreased LBW. Measures to improve the implementation of this simple intervention should help to address India's burden of LBW. [ABSTRACT FROM AUTHOR]

Background: Whether non-communicable diseases (NCDs) are diseases of poverty or affluence in low-and-middle income countries has been vigorously debated. Most analyses of NCDs have used self-reported data, which is biased by differential access to healthcare services between groups of different socioeconomic status (SES). We sought to compare self-reported diagnoses versus standardised measures of NCD prevalence across SES groups in India. Methods: We calculated age-adjusted prevalence rates of common NCDs from the Study on Global Ageing and Adult Health, a nationally representative cross-sectional survey. We compared self-reported diagnoses to standardized measures of disease for five NCDs. We calculated wealth-related and education-related disparities in NCD prevalence by calculating concentration index (C), which ranges from −1 to +1 (concentration of disease among lower and higher SES groups, respectively). Findings: NCD prevalence was higher (range 5.2 to 19.1%) for standardised measures than self-reported diagnoses (range 3.1 to 9.4%). Several NCDs were particularly concentrated among higher SES groups according to self-reported diagnoses (Csrd) but were concentrated either among lower SES groups or showed no strong socioeconomic gradient using standardized measures (Csm): age-standardised wealth-related C: angina Csrd 0.02 vs. Csm −0.17; asthma and lung diseases Csrd −0.05 vs. Csm −0.04 (age-standardised education-related Csrd 0.04 vs. Csm −0.05); vision problems Csrd 0.07 vs. Csm −0.05; depression Csrd 0.07 vs. Csm −0.13. Indicating similar trends of standardized measures detecting more cases among low SES, concentration of hypertension declined among higher SES (Csrd 0.19 vs. Csm 0.03). Conclusions: The socio-economic patterning of NCD prevalence differs markedly when assessed by standardized criteria versus self-reported diagnoses. NCDs in India are not necessarily diseases of affluence but also of poverty, indicating likely under-diagnosis and under-reporting of diseases among the poor. Standardized measures should be used, wherever feasible, to estimate the true prevalence of NCDs. [ABSTRACT FROM AUTHOR]

Background: HIV and risky alcohol use are intertwined public health issues in sub-Saharan Africa. Research supports the association between alcohol and unprotected sex, but there is limited data using event-level analysis to examine this relationship. Methods: Using data from Demographic Health Surveys and AIDS Information Surveys collected in 8 sub-Saharan African countries (Kenya, Lesotho, Mozambique, Rwanda, Swaziland, Tanzania, Zambia, and Zimbabwe) drunkenness (reporting male partner or both male and female partner being drunk during last sexual intercourse) at last sex was tested as a predictor of unprotected last sex among the male (n = 24,512) and female (n = 28,229) participants. Partner type, HIV test results, and the other variables were evaluated as effect modifiers of this relationship. Results: Drunkenness at last sex had a negative effect on the likelihood of condom use among men (AOR 0.84, 95% CI 0.72-0.99) and a marginally significant effect among women (AOR 0.87, 95% CI 0.59-1.02) in Southern Africa. However, for men in Southern Africa, this effect was primarily observed with steady partners. Contrary to predictions, in both Southern and Eastern Africa, for men, drunkenness during sex with casual partners increased the odds of condom use. Conclusions: These data indicate a need to implement HIV prevention efforts that consider the role of alcohol use in precipitating unprotected sex and how it varies based upon partner type. [ABSTRACT FROM AUTHOR]

Background: There is considerable evidence of racial/ethnic patterning of sexually transmitted infection (STI) risk in the United States. There is also evidence that poorer persons are at increased STI risk. Evidence regarding the interaction of race/ethnicity and income is limited, particularly nationally at the individual level. Methods: We examined the pattern of socioeconomic gradients in STI infection among young people in a nationwide US study and determined how these gradients varied by race/ethnicity. We estimated the cumulative diagnosis prevalence of chlamydia, gonorrhea, or trichomoniasis (via self-report or laboratory confirmation) for young adults (ages, 18-26 years old) Hispanics and non-Hispanic whites, blacks, and others across income quintiles in the Add Health data set. We ran regression models to evaluate these relationships adjusting for individual- and school-level covariates. Results: Sexually transmitted infection diagnosis was independently associated with both racial/ethnic identity and with low income, although the racial/ethnic disparities were much larger than income-based ones. A negative gradient of STI risk with increasing income was present within all racial/ethnic categories, but was stronger for nonwhites. Conclusions: Both economic and racial/ethnic factors should be considered in deciding how to target STI prevention efforts in the United States. Particular focus may be warranted for poor, racial/ethnic minority women. [ABSTRACT FROM AUTHOR]

Background: A growing literature suggests that low birth weight increases the risk of poor health outcomes in adulthood. We tested this hypothesis among young adults living in São Paulo State, Brazil. Methods and Findings: To identify the effects of low birth weight on young adulthood outcomes, a medical assessment of 297 individuals born between 1977 and 1989 was conducted at a primary care unit in São Paulo State, Brazil. We analyzed body mass index (BMI), waist-hip ratio, blood pressure, fasting glucose and total cholesterol levels using linear and logistic regressions. Low birth was negatively associated with BMI (β = −2.0, 95% CI: −3.69, −0.27, p = 0.02), fasting glucose levels (β = −1.9, 95% CI: −3.9, −0.07, p = 0.05), waist-hip ratio (β = −0.03, 95% CI: −0.07, −0.01, p = 0.10), systolic blood pressure (β = −3.32, 95% CI: −7.60, 0.96, p = 0.12), and total cholesterol levels (β = −3.19, 95% CI: −16.43, 10.05, p = 0.636). Low birth weight was also associated with lower odds of young adults being overweight and obese, but neither association was statistically significant. Weight gain in the first 12 months of life was associated with higher adult BMI (β = 0.79, 95% CI: −0.0455, 1.623, p = 0.064) and blood pressure (β = 2.79, 95% CI: 0.22, 5.35, p = 0.034). No associations were found between low birth weight and early life (catch-up) growth. Conclusions: Low birth weight was not associated with poor health outcomes among young adults in Brazil. These results appear inconsistent with the original Barker hypothesis, but will need to be corroborated in larger samples with longer follow-ups to allow a more general evaluation of the validity of the hypothesis in low and middle income countries. [ABSTRACT FROM AUTHOR]

Objective: We examined body mass index (BMI) across place and time to determine the pattern of BMI mean and standard deviation trajectories. Methods: We included participants in the Framingham Heart Study (FHS) Offspring Cohort over eight waves of follow-up, from 1971 to 2008. After exclusions, the final sample size was 4569 subjects with 28,625 observations. We used multi-level models to examine population means and variation at the individual and neighborhood (census tracts) levels across time with measured BMI as the outcome, controlling for individual demographics and behaviors and neighborhood poverty. Because neighborhoods accounted for limited BMI variance, we removed this level as a source of variation in final models. We examined sex-stratified models with all subjects and models stratified by sex and baseline weight classification. Results: Mean BMI increased from 24.0 kg/m2 at Wave 1 to 27.7 at Wave 8 for women and from 26.6 kg/m2 to 29.0 for men. In final models, BMI variation also increased from Waves 1 to 8, with the standard deviation increasing from 4.18 kg/m2 to 6.15 for women and 3.31 kg/m2 to 4.73 for men. BMI means increased in parallel across most baseline BMI weight classifications, except for more rapid increases through middle-age for obese women followed by declines in the last wave. BMI standard deviations also increased in parallel across baseline BMI classifications for women, with greater divergence of BMI variance for obese men compared to other weight classifications. Conclusion: Over nearly 40 years, BMI mean and variation increased in parallel across most baseline weight classifications in our sample. Individual-level characteristics, especially baseline BMI, were the primary factors in rising BMI. These findings have important implications not only for understanding the sources of the obesity epidemic in the United States but also for the targeting of interventions to address the epidemic. [ABSTRACT FROM AUTHOR]

Background: Public health research has turned towards examining upstream, community-level determinants of cardiovascular disease risk factors. Objective measures of the environment, such as those derived from direct observation, and perception-based measures by residents have both been associated with health behaviours. However, current methods are generally limited to objective measures, often derived from administrative data, and few instruments have been evaluated for use in rural areas or in low-income countries. We evaluate the reliability of a quantitative tool designed to capture perceptions of community tobacco, nutrition, and social environments obtained from interviews with residents in communities in 5 countries. Methodology/Principal Findings: Thirteen measures of the community environment were developed from responses to questionnaire items from 2,360 individuals residing in 84 urban and rural communities in 5 countries (China, India, Brazil, Colombia, and Canada) in the Environmental Profile of a Community's Health (EPOCH) study. Reliability and other properties of the community-level measures were assessed using multilevel models. High reliability (>0.80) was demonstrated for all community-level measures at the mean number of survey respondents per community (n = 28 respondents). Questionnaire items included in each scale were found to represent a common latent factor at the community level in multilevel factor analysis models. Conclusions/ Significance: Reliable measures which represent aspects of communities potentially related to cardiovascular disease (CVD)/risk factors can be obtained using feasible sample sizes. The EPOCH instrument is suitable for use in different settings to explore upstream determinants of CVD/risk factors. [ABSTRACT FROM AUTHOR]

Summary Sabarwal S, Subramanian SV, McCormick MC, Silverman JG. Husband's preference for a son and women's nutrition: examining the role of actual and desired family composition on women's anaemia and body mass index in India. Paediatric and Perinatal Epidemiology 2012; 26: 77-88. This study examines the relationship between the husband's preference for a son, sex composition of children and risk of anaemia and underweight among married Indian women. Information was collected regarding 29 517 couples having at least one child in the nationally representative 2005-06 National Family Health Survey of India. The exposures were husband's preference for a son and sex composition of children: sons only, daughters only and mixed. Outcome included maternal underweight and moderate/severe anaemia. Husband's preference for a son was not found to be associated with his wife's risk of anaemia or underweight. Sex composition of the children was modestly associated with increased odds of anaemia among women from households with daughters only as compared with those with sons only [AOR: 1.19; 95% CI 1.04, 1.35]. The findings from this population-based study of socio-cultural norms around preference for a son and married Indian women's nutritional status do not support the hypothesis that husband's preference for sons influences the nutritional status of their wives. However, having daughters only is associated with maternal anaemia for reasons that remain to be established. [ABSTRACT FROM AUTHOR]

A letter to the editor and a response from the author are presented on the article concerning comprehensive evaluation of trends in body-mass index (BMI) in 199 countries.

Background: Adult height is a useful biological measure of long term population health and well being. We examined the cohort differences and socioeconomic patterning in adult height in low- to middle-income countries. Methods/Findings: We analyzed cross-sectional, representative samples of 364538 women aged 25-49 years drawn from 54 Demographic and Health Surveys (DHS) conducted between 1994 and 2008. Linear multilevel regression models included year of birth, household wealth, education, and area of residence, and accounted for clustering by primary sampling units and countries. Attained height was measured using an adjustable measuring board. A yearly change in birth cohorts starting with those born in 1945 was associated with a 0.0138 cm (95% CI 0.0107, 0.0169) increase in height. Increases in heights in more recent birth year cohorts were largely concentrated in women from the richer wealth quintiles. 35 of the 54 countries experienced a decline (14) or stagnation (21) in height. The decline in heights was largely concentrated among the poorest wealth quintiles. There was a strong positive association between height and household wealth; those in two richest quintiles of household wealth were 1.988 cm (95% CI 1.886, 2.090) and 1.018 cm (95% CI 0.916, 1.120) taller, compared to those in the poorest wealth quintile. The strength of the association between wealth and height was positive (0.05 to 1.16) in 96% (52/54) countries. Conclusions: Socioeconomic inequalities in height remain persistent. Height has stagnated or declined over the last decades in low- to middle-income countries, particularly in Africa, suggesting worsening nutritional and environmental circumstances during childhood. [ABSTRACT FROM AUTHOR]

Background: The dimensions along which mortality is patterned in India remains unclear. We examined the specific contribution of social castes, household income, assets, and monthly per capita consumption to mortality differentials in India. Methods and Findings: Cross-sectional data on 217 363 individuals from 41 554 households from the 2004-2005 India Human Development Survey was analyzed using multiple logistic regressions. Mortality differentials across social castes were attenuated after adjusting for household economic factors such as income and assets. Individuals living in the lowest income and assets quintiles had an increased risk of mortality with odds ratio (OR) of 1.66 (95% CI = 1.23-2.24) in the bottom income quintile and OR of 2.94 (95% CI = 1.66-5.22) in the bottom asset quintile. Counter-intuitively, individuals living in households with lowest monthly consumption per capita had significantly lower probability of death (OR = 0.27, 95% CI = 0.20-0.38). Conclusions: Mortality burden in India is largely patterned on economic dimensions as opposed to caste dimensions, though caste may play an important role in predicting economic opportunities. [ABSTRACT FROM AUTHOR]

Background Social support may be particularly important in countering depression among systematically disadvantaged groups. Latino immigrants are an example of a disadvantaged population that has better than expected mental health outcomes. One explanation put forth for this pattern is strong social support from kin networks. Studies on the effect of social support on mental health often assess the quantity of social ties rather than the quality of the support they provide. In addition, such studies rarely specify the source of support and how support from family versus friends may differentially impact mental health. Methods In this study, data from the Project on Human Development in Chicago Neighbourhoods were used to disaggregate the effects of source-specific emotional support on risk of depression. Second, the relationship between ethnicity/nativity status and risk of depression was examined. Finally, whether the relationship between family-based and friend-based social support and depression differed across ethnic/nativity status was explored. Results Support from both family and friends had protective effects on risk of depression; however, when mutually adjusted, only kin support remained statistically significant. At higher levels of family support, foreign-born Mexicans and African Americans had decreased risk of depression than at low levels of family support. Conclusion This study provides evidence that family support may be more important than non-kin support for mental health. Findings also suggest that the effects of family support on risk of depression vary by ethnicity and nativity status. Preservation of naturally occurring support resources among some groups may be a way to maintain mental health. [ABSTRACT FROM AUTHOR]

Background Social support may be particularly important in countering depression among systematically disadvantaged groups. Latino immigrants are an example of a disadvantaged population that has better than expected mental health outcomes. One explanation put forth for this pattern is strong social support from kin networks. Studies on the effect of social support on mental health often assess the quantity of social ties rather than the quality of the support they provide. In addition, such studies rarely specify the source of support and how support from family versus friends may differentially impact mental health. Methods In this study, data from the Project on Human Development in Chicago Neighbourhoods were used to disaggregate the effects of source-specific emotional support on risk of depression. Second, the relationship between ethnicity/nativity status and risk of depression was examined. Finally, whether the relationship between family-based and friend-based social support and depression differed across ethnic/nativity status was explored. Results Support from both family and friends had protective effects on risk of depression; however, when mutually adjusted, only kin support remained statistically significant. At higher levels of family support, foreign-born Mexicans and African Americans had decreased risk of depression than at low levels of family support. Conclusion This study provides evidence that family support may be more important than non-kin support for mental health. Findings also suggest that the effects of family support on risk of depression vary by ethnicity and nativity status. Preservation of naturally occurring support resources among some groups may be a way to maintain mental health. [ABSTRACT FROM PUBLISHER]

Background Several European studies have found significant small area variation in the risk of childhood onset (type 1) diabetes (T1D) which has been interpreted as evidence for contextual determinants of T1D. However, this conclusion may be fallacious since the limited number of newborn infants and the low risk for T1D is a source of spurious variability not properly handled by usual statistical methods. This study investigates the existence of contextual effects in the genesis of T1D, compares conclusions in previous reports with results obtained in a multilevel regression framework and highlights analysis of variance as a useful approach in public health. Methods All singletons born in Sweden between 1987 and 1991 were identified in the Medical Birth Registry (n=560 766) and followed for diabetes until age 14 using the Hospital Discharge Registry. Area variation in the cumulative incidence of T1D was estimated by different statistical methods including multilevel logistic regression. Results The risk of T1D ranged from 4.3 to 6.5 per 1000 newborns across the counties (n=24) and from 0.0 to 19.2 per 1000 newborns across the municipalities (n=284). These differences were significant in standard statistical tests (counties, p=0.02; municipalities, p=0.007). However, according to multilevel analyses, the risk of T1D ranged from 4.7 to 5.7 and from 4.4 to 6.0 per 1000 newborns in counties and municipalities, respectively, and the area variation was small and without practical relevance (counties, σ2=0.006; municipalities, σ2=0.017). Conclusions Previous reports based on standard statistical tests are misleading. According to multilevel analysis, administrative areas have minor relevance for individual risk of T1D in Sweden. [ABSTRACT FROM AUTHOR]

The concept of adaptation has been defined too rigidly by evolutionary psychologists so as to exclude modern conditions. This article proposes a more flexible, and useful, application of the term. Among animals with extensive social learning, adaptations must include behaviors that enhance current fitness on average (rather than over the distant past). Because the content of social learning is non genetic, it is selected directly via the phenotype and immediate fitness consequences. Used thus, the concept of adaptation provides a viable research strategy for investigating differences among modern societies. These concepts are illustrated concerning intelligence as a function of the varied cognitive demands of different societies. The author concludes that societal variation in intelligence (including the Flynn effect) is best understood in terms of responses by individuals to varied levels of cognitive enrichment. Research on intelligence thus illustrates the value of a more flexible definition of adaptation than the genetic-determinist one preferred by most evolutionary psychologists. [ABSTRACT FROM AUTHOR]

Objective To assess the value of self-rated health assessments by examining the association between education and self-rated poor health. Methods We used the globally representative population-based sample from the 2002 World Health Survey, composed of 219 713 men and women aged 25 and over in 69 countries, to examine the association between education and self-rated poor health. In a binary regression model with a logit link function, we used self-rated poor health as the binary dependent variable, and age, sex and education as the independent variables. Findings Globally, there was an inverse association between years of schooling and self-rated poor health (odds ratio, OR: 0.929; 95% confidence interval, CI: 0.926--0.933). Compared with the individuals in the highest quintile of years of schooling, those in the lowest quintile were twice as likely to report poor health (OR: 2.292; 95% CI: 2.165--2.426). We found a dose--response relationship between quintiles of years of schooling and the ORs for reporting poor health. This association was consistent among men and women; low-, middle- and high-income countries; and regions. Conclusion Our findings suggest that self-reports of health may be useful for epidemiological investigations within countries, even in low-income settings. [ABSTRACT FROM AUTHOR]

Background: Childhood asthma prevalence and morbidity have been shown to vary by neighborhood. Less is known about between-school variation in asthma prevalence and whether it exists beyond what one might expect due to students at higher risk of asthma clustering within different schools. Our objective was to determine whether between-school variation in asthma prevalence exists and if so, if it is related to the differential distribution of individual risk factors for and correlates of asthma or to contextual influences of schools. Methods: Cross-sectional analysis of 16,640 teens in grades 7-12 in Wave 1 (data collected in 1994-5) of the National Longitudinal Study of Adolescent Health. Outcome was current diagnosis of asthma as reported by respondents' parents. Two-level random effects models were used to assess the contribution of schools to the variance in asthma prevalence before and after controlling for individual attributes. Results: The highest quartile schools had mean asthma prevalence of 21.9% compared to the lowest quartile schools with mean asthma prevalence of 7.1%. In our null model, the school contributed significantly to the variance in asthma (σu0² = 0.27, CI: 0.20, 0.35). Controlling for individual, school and neighborhood attributes reduced the between-school variance modestly (σu0² = 0.19 CI: 0.13-0.29). Conclusion: Significant between-school variation in current asthma prevalence exists even after controlling for the individual, school and neighborhood factors. This provides evidence for school level contextual influences on asthma. Further research is needed to determine potential mechanisms through which schools may influence asthma outcomes. [ABSTRACT FROM AUTHOR]

Background: Recent studies have emphasized the role of psychosocial stressors as a determinant of asthma, and neighborhoods can be a potential source of such stressors. We investigated the association between parental perception of neighborhood safety and reported lifetime asthma among children. Methodology/Principal Findings: Data for the study came from the 2003-04 National Survey of Children Health (NSCH); a nationally representative cross-sectional sample of children aged 0-17 years. Demographic, socioeconomic and behavioral covariates were included in the study. Models were estimated after taking account of weighting and complex survey design. Parental report of whether the child has ever been diagnosed with asthma by a physician was used to define the outcome. Parental report of perception of neighborhood safety was the main exposure. In unadjusted models, the odds ratio (OR) for reporting asthma associated with living in neighborhoods that were perceived to be sometimes or never safe was 1.36 (95% confidence intervals [CI] 1.21, 1.53) compared to living in neighborhoods that were perceived to be always safe. Adjusting for covariates including exposure to second hand tobacco smoke, mother's self-rated health, child's physical activity and television viewing attenuated this association (OR 1.25, 95% CI 1.08, 1.43). In adjusted models, the increased odds ratio for reporting asthma was also higher among those who perceived neighborhoods as being usually safe (OR 1.15 95% CI 1.06, 1.26), as compared to always safe, suggestive of a dose-response relationship, with the differentials for usually safe and never safe being statistically significant (p = 0.009). Conclusion: Psychosocial stressors may be important risk factors that may impact the pathogenesis of asthma and/or contribute to asthma morbidity by triggering exacerbations through neuroimmunologic mechanisms, as well as social mechanisms. [ABSTRACT FROM AUTHOR]

The article presents research examining the association between maternal height and child mortality, anthropometric failure, and anemia in India. The design and setting of the study involving data analysis of information on mothers and children taken from the 2005-2006 national Family Health Survey in India is explained. Outcomes measured included mortality, stunting, wasting, and anemia. Results indicated that maternal height was inversely associated with child mortality and anthropometric failure in a representative sample of households in India.

Objectives. We assessed the relative contribution of Hispanic ethnicity, country of origin, and nativity to lifetime prevalence of asthma among mothers and children enrolled in the Project on Human Development in Chicago Neighborhoods. Methods. We used multilevel models to analyze data from wave 3 of the Project on Human Development in Chicago Neighborhoods study (2000 to 2001 ). Mothers reported physician-diagnosed asthma for themselves and their children. Maternal race, ethnicity, country of origin, and nativity were the predictors of interest. Results. We found substantial heterogeneity in lifetime asthma within Hispanic subgroups for mothers and children. Hispanics of non-Mexican origin had greater odds of having asthma than did non-Hispanic Whites; respondents of Mexican origin did not differ from non-Hispanic Whites. Odds of experiencing asthma were more strongly related to nativity than to race, Hispanic ethnicity, or country of origin. Only immigrant Mexicans reported asthma prevalence lower than that of native non-Hispanic Whites. Conclusions. Nativity is a strong predictor of lifetime asthma prevalence, suggesting the importance of potential interactions between genetic susceptibilities and environmental factors in both the native and the host countries. (Am J Public Health. 2009;99:690-697. doi:10.2105/AJPH.2007.128843) [ABSTRACT FROM AUTHOR]

Objective: Little is known about whether economic crises widen health inequalities. Japan experienced more than 10 years of economic recession beginning in the 1990s. The question of whether socioeconomic-based inequality in self-rated health widened after the economic crisis was examined. Design, setting and participants: Repeated cross- sectional survey design. Two pooled datasets from 1986 and 1989 and from 1998 and 2001 were analysed separately, and temporal change was examined. The study took place in Japan among the working-age population (20-60 years old). The two surveys consisted of 168 801 and 150 016 people, respectively, with about an 80% response rate. Results: The absolute percentages of people reporting poor health declined across all socioeconomic statuses following the crisis. However, after controlling for confounding factors, the odds ratio (OR) for poor self- rated health (95% confidence intervals) among middle- class non-manual workers (clerical/sales/service workers) compared with the highest class workers (managers/ administrators) was 1.02 (0.92 to 1.14) before the crisis but increased to 1.14 (1.02 to 1.29) after the crisis (p for temporal change = 0.02). The association was stronger among males. The adjusted ORs among professional workers and young female homemakers also marginally increased over time. Unemployed people were twice as likely to report poor health compared with the highest class workers throughout the period. Self-rated health of people with middle to higher incomes deteriorated in relative terms following the crisis compared with that of lower income people. Conclusions: Self-rated health improved in absolute terms for all occupational groups even after the economic recession. However, the relative disparity increased between the top and middle occupational groups in men. [ABSTRACT FROM AUTHOR]

In this article, the authors investigate the nature of health inequalities in India using groupings that have historical as well as social significance. The authors examine the extent to which health in India gets stratified along gender, caste, religion, education, wealth and urban-rural dimensions. They base their study on the nationally representative 1998-1999 Indian National Family Health Survey (INFHS) data. They note that the assessment of independent and relative contribution is important both for understanding the etiology of the distribution of health in a population and for shaping policy.

While a growing body of literature has investigated the health impact of intimate partner violence (IPV), less has been written on the social determinants of IPV. The authors use multilevel modeling methods to analyze data from a sample of 83,627 women in India to examine the socioeconomic and demographic patterning of the state- and neighborhood-level variation in, and the state- and/or neighborhood-level characteristics related to, IPV. This study finds social gradients in IPV in which women who are uneducated, from marginalized castes, and living in poor households have higher likelihood of reporting IPV than those living in advantaged circumstances. The results also show differences in IPV between neighborhoods and between states that are partially explained by state levels of gender inequality. The results suggest that changing cultural norms to promote the status of women and increasing the educational and economic opportunities for all people could decrease the prevalence of IPV. [ABSTRACT FROM AUTHOR]

The article reports on a multilevel framework for epidemiologic research on asthma disparities. It discusses the increasing prevalence and marked disparities in asthma in the United States and worldwide. The article suggests that a multilevel approach that includes an ecological perspective may help to explain heterogeneities in asthma expression across socioeconomic and geographic boundaries.

Objective In Brazil, it was previously reported that in hospital perinatal, neonatal and infant mortality rates are higher for hospitals contracted to the National Public Health System (SUS) compared with non-SUS hospitals. We analyse whether this reflects a compositional effect (selection of patients) or a contextual effect. Design Population-based cohort study. Setting Belo Horizonte, Brazil, 1999. Population A total of 36 469 births in 24 hospitals. Methods A multilevel analysis was carried out using information gathered at the individual level on maternal education (used as an indicator of socio-economic status), maternal age, type of pregnancy and delivery, birthweight and sex of the fetus. Main outcome measure Perinatal death. Results Risk factors for perinatal death included male sex (OR = 1.25; 95% CI 1.01–1.55), birthweight of 1500–2500 g (OR = 7.65; 95% CI 5.74–10.20), birthweight of 500–1500 g (OR = 187.54; 95% CI 141.31–248.39), less than 4 years of maternal education (OR = 2.93; 95% CI 1.68–5.10), as well as birth at private-SUS (OR = 2.92; 95% CI 1.87–4.54) or philanthropic-SUS hospitals (OR = 1.81; 95% CI 1.12–2.92). After controlling for individual characteristics, there was still a significant variation in perinatal deaths between hospitals categories. Conclusion Independent of compositional (or individual) characteristics, hospital factors exert an influence on the risk of perinatal death, primarily hospital category related to SUS. Considering the highest proportion of births in SUS hospitals in Brazil, especially private-SUS hospitals, improving hospital quality of care is an urgent priority for reducing the toll of perinatal and infant mortality, as well as inequalities in these outcomes. [ABSTRACT FROM AUTHOR]

Objectives: Developing countries are increasingly characterised by the simultaneous occurrence of under- and overnutrition. This study examined the association between contextual income inequality and the double burden of under- and overnutrition in India. Design: A population-based multilevel study of 77 220 ever married women, aged 15-49 years, from 26 Indian states, derived from the 1998-99 Indian National Family Health Survey data. The World Health Organization recommended categories of body mass index constituted the outcome, and the exposure was contextual measure of state income inequality based on the Gini coefficient of per capita consumption expenditure. Covariates included a range of individual demographic, socioeconomic, behavioural and morbidity measures and state-level economic development. Results: In adjusted models, for each standard deviation increase in income inequality, the odds ratio for being underweight increased by 19% (p = 0.02) and the odds ratio for being obese increased by 21% (p<0.0001). Income inequality had a similar effect on the risk of being overweight as it did on the risk of obesity (p = 0.01), and state income inequality increased the risk of being pre-overweight by 9% (p = 0.01). While average levels of state economic development were strongly associated with degrees of overnutrition, no association was found with the risk of being underweight. Conclusions: Rapidly developing economies, besides experiencing paradoxical health patterns, are typically characterised by increased levels of income inequality. This study suggests that the twin burden of undernutrition and overnutrition in India is more likely to occur in high-inequality states. Focusing on economic equity via redistribution policies may have a substantial impact in reducing the prevalence of both undernutrition and overnutrition. [ABSTRACT FROM AUTHOR]

Objectives: To simultaneously examine the effects of area-level and individual-level socioeconomic position on fatal injuries in children <5 years of age. Methods: A retrospective cohort study based on the national birth and death registers of Korea. 2 667 060 children born during 1995-8 were followed up from birth to the 5th birthday. Cumulative incidences of fatal injuries were calculated, and through multilevel Poisson regression models, relative risks (RRs) of incidence rate were estimated according to children's sex, father's occupation and mother's education at individual level, and deprivation and degree of urbanity at area level. Results: Girls had lower risk for fatal injuries than boys (RR 0.81; 95% confidence interval (CI) 0.75 to 0.87). Compared with children with fathers in non-manual occupations, those with fathers in manual (RR 1.45; 95% CI 1.34 to 1.58) or other occupations (RR 1.35; 95% CI 1.13 to 1.62) had higher risk. Children with mothers who were high school graduates (RR 1.23; 95% CI 1.12 to 1.36) or junior school graduates (RR 1.91; 95% CI 1.66 to 2.19) had higher risk than those whose mothers were college graduates. After controlling for individual-level variables, residence in more deprived districts (RR 1.13; 95% CI 1.05 to 1.21) or non- metropolitan regions (urban RR 1.34; 95% CI 1.22 to 1.47 and rural RR 1.61; 95% Cl 1.40 to 1.86) was significantly associated with increased risk. Conclusions: Both individual-level and area-level socioeconomic position influenced the risk for childhood fatal injuries. To reduce the socioeconomic inequalities and the absolute burden in Korea, universal strategies should receive priority, and special efforts in implementation should be directed towards both disadvantaged households and areas. [ABSTRACT FROM AUTHOR]

The aim of this study is to estimate the impact of neighbourhoods on educational outcome for adolescents in Sweden. Using a multilevel statistical approach and the PLACE database that consists of a census of individuals in 1990–2000 in Sweden, the paper explores different domains of neighbourhood characteristics that predict educational outcomes in adolescents. Educational achievement in year 2000 was measured for three cohorts, geocoded to their neighbourhood environments. It was found that neighbourhood characteristics related to socioeconomic resources and demographic stability are predictors of individual educational outcomes. A strong association between neighbourhood socio-cultural capital variables and education were also observed. Despite national policies on availability and access to education in Sweden, there are substantial inequalities in educational outcomes that are not simply a result of differences in individual characteristics. [ABSTRACT FROM AUTHOR]

Background Systematic evidence on the patterns of health deprivation among indigenous peoples remains scant in developing countries. We investigate the inequalities in mortality and substance use between indigenous and non-indigenous, and within indigenous, groups in India, with an aim to establishing the relative contribution of socioeconomic status in generating health inequalities. Methods and Findings Cross-sectional population-based data were obtained from the 1998-1999 Indian National Family Health Survey. Mortality, smoking, chewing tobacco use, and alcohol use were four separate binary outcomes in our analysis. Indigenous status in the context of India was operationalized through the Indian government category of scheduled tribes, or Adivasis, which refers to people living in tribal communities characterized by distinctive social, cultural, historical, and geographical circumstances. Indigenous groups experience excess mortality compared to non-indigenous groups, even after adjusting for economic standard of living (odds ratio 1.22; 95% confidence interval 1.13- 1.30). They are also more likely to smoke and (especially) drink alcohol, but the prevalence of chewing tobacco is not substantially different between indigenous and non-indigenous groups. There are substantial health variations within indigenous groups, such that indigenous peoples in the bottom quintile of the indigenous-peoples-specific standard of living index have an odds ratio for mortality of 1.61 (95% confidence interval 1.33-1.95) compared to indigenous peoples in the top fifth of the wealth distribution. Smoking, drinking alcohol, and chewing tobacco also show graded associations with socioeconomic status within indigenous groups. Conclusions Socioeconomic status differentials substantially account for the health inequalities between indigenous and non-indigenous groups in India. However, a strong socioeconomic gradient in health is also evident within indigenous populations, reiterating the overall importance of socioeconomic status for reducing population-level health disparities, regardless of indigeneity. [ABSTRACT FROM AUTHOR]

Objective: The study examines whether an individual's sexual behaviour is associated with the demographic context within which they live. Methods: Data from a large behavioural survey were matched to the census and the number of opposite sex partners individuals reported having in the year before interview was modelled against a suite of individual characteristics and analogous characteristics for the population in which they lived. Results: The number of partners reported (none, one, two, three, or more) were variously associated with an individual's gender, age, marital status, sexual identity, and same sex activity in the previous year. Additionally, population age structure, sex ratio, and the proportion of the population reporting specific patterns of sexual activity were associated with the behaviour of individuals. Conclusions: This study demonstrates that population context is associated with individual behaviour even after individual characteristics have been taken into account. This suggests that multilevel modelling of sexual behaviour data can provide new insights into the pattern of sexual behaviour. [ABSTRACT FROM AUTHOR]

Objectives. The purpose of this study was to investigate the independent relationship between neighborhood context (characterized through age structure, economic conditions, service provision, and residential stability) and self-reported health among elders in one U.S. city. Methods. By using multilevel statistical models, we examined the cross-sectional relationships between markers of neighborhood environment (derived from the 1980 U.S. Census and the Yellow Pages of the 1985 New Haven, Connecticut, telephone book) and self-rated health among elders. We used survey data from the 1985 New Haven Established Populations for Epidemiologic Studies of the Elderly, which comprised 1,926 elders nested within 28 census tracts. Results. When controlled for individual age, gender, race, marital status, education, and income, neighborhood measures of percent poverty were positively associated with poor self-rated health (odds ratio [OR] = 1.09; 95% confidence interval [CI] = 1.02–1.17), whereas residential stability (OR = 0.90; 95% CI = 0.84–0.96) and concentration of elders (OR = 0.82; 95% CI = 0.72–0.94) were inversely associated with poor self-rated health. Neighborhood service density was not associated with self-rated health. Discussion. We found support for the role of neighborhood structural context (reflected through measures of poverty, residential stability, and age-based demographic concentration) in predicting the health of elders. Density of neighborhood services did not appear to have an independent effect on the self-rated health of elders. [ABSTRACT FROM AUTHOR]